RN Transitional Care Coordinator for Oro Valley Hospital

at Arizona Community Physicians

Job Description

Job Summary

Works under the direction of the ACO Medical Director in the area of Transitional Care Management and Case Management. A prime area of focus will be transitional care management of emergency department patients and inpatients in an acute care facility. Other areas of focus may include chronic care management, population health management, quality improvement, and provider and staff education.

Minimum Qualifications

Education: Completion of an accredited RN program.

Work Experience: Minimum of two years of experience with hospital case management, home health case management or SNF case management.

Skill / Requirements

Responsibilities

Clinical: Assist physician offices and patients in post hospital and SNF discharge care and act as a liaison with all ACP physicians and outside medical providers, where appropriate. Work collaboratively with hospital, SNF and home health case managers. Develop processes and procedures to thoroughly review reports to identify at risk patients and coordinate the necessary medical and community services. Monitor hospital admissions, lengths of stay, and emergency room visits and monitor gaps of care reports and provide feedback as needed. Assist in quality improvement efforts with ACO and hospital staff.

Act as a liaison between community resources helpful to patients (e.g. volunteer agencies, assistance programs) and ACP staff and providers. Use advocacy, communication and resource management, while promoting quality and cost-effective interventions and outcomes. Facilitate the achievement of patient wellness and autonomy through advocacy, assessment, planning, communication, education, resource management, and service facilitation. Maintain appropriate documentation to track quality improvement and cost reduction activity

Teamwork: Works harmoniously with others, demonstrating a commitment to achieving common goals. Communicates in a manner that promotes trust and mutual respect. Maintains a professional demeanor in dealing with conflict and difficult issues. Adapts to changes in job duties and workplace with a positive and cooperative demeanor.

Attendance: Accurately records arrival/departure times and hours worked and adheres to the established attendance policy. Contacts supervisor appropriately with any schedule deviation.